Acute Pancreatitis as the Index Manifestation of Parathyroid Adenoma

Abstract

Acute pancreatitis is one of the most common clinical emergencies encountered in our day-to-day practice. Although gallstones are the most common cause worldwide, alcohol consumption remains the leading cause of acute pancreatitis in the Indian population. We report a rare case of parathyroid adenoma, which presented with acute pancreatitis as its initial manifestation in an elderly patient. A 65-year-old gentleman with acute abdominal pain, distension, and obstipation, underwent emergency laparotomy in view of acute intestinal obstruction and was found to have acute pancreatitis intra-operatively. On post-operative evaluation, his serum calcium was >14 mg/dl and serum parathormone (PTH) was >2,000 pg/ml. Single-photon emission computed tomography (SPECT) and technetium (Tc-99m) sestamibi scintigraphy revealed a right inferior parathyroid adenoma, which was surgically excised, following which the patient made an uneventful recovery. Hypercalcemia induced by hyperparathyroidism causes auto-activation of pancreatic enzymes within the pancreatic parenchyma and is also believed to cause pancreatic duct obstruction by calcium deposition, thus causing pancreatitis. Radionucleotide scan, in addition to contrast-enhanced computed tomography, can help in localizing the lesion causing hyperparathyroidism. Appropriate resuscitation and stabilization with anti-hypercalcemic measures, including hydration and forced calciuresis, followed by surgery form the mainstay of treatment in patients with primary hyperparathyroidism. Patients with acute pancreatitis without a history of gallstone disease or alcohol intake should be evaluated for other rare causes. Early diagnosis and prompt treatment of the underlying condition can prevent the recurrence of pancreatitis.

Keywords: hypercalcemia; hyperparathyroidism; intestinal obstruction; spect; tc-99m sestamibi.

Figure 1. Plain radiograph of the abdomen - erect view showing multiple dilated small bowel loops with air-fluid levels (arrows).

Figure 2. (A) Three-dimensional CT scan and (B) SPECT scintigraphy showing a right inferior parathyroid adenoma (arrow).

SPECT, single-photon emission computed tomography.

Figure 3. (A) Technetium (Tc-99m) sestamibi nucleotide scan showing increased tracer uptake in a soft tissue lesion in the right para-tracheal region. (B) Delayed images showed persistent tracer retention in the focal uptake suggestive of an adenoma in the right inferior parathyroid gland (arrow).